The incidence of treated end-stage renal disease in New Zealand Maori and Pacific Island people and in Indigenous Australians.

BACKGROUND: Although Indigenous Australians, New Zealand Maori and Pacific Island people comprise an unduly high proportion of patients treated for end-stage renal disease (ESRD) in the two countries, no population-based age- and disease-specific rates have been published. METHODS: From data provided to the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA), truncated age- and sex-standardized incidence rates were calculated for treated ESRD due to all causes and by primary renal disease, in four broad age groups of Maori, Pacific Island people and all 'other' New Zealanders and Indigenous and non-indigenous Australians, for the period 1992-2001. RESULTS: The incidence of ESRD did not differ in persons aged 0-14 years. In adults, Maori and Pacific Island people had similar rates of ESRD, a little more than half those of Indigenous Australians except in persons aged 65 years and over in whom the rates were nearly equal, but two to ten times the rates in 'other' New Zealanders and non-indigenous Australians. The excess of ESRD in Indigenous Australians was due principally to type II diabetic nephropathy and glomerulonephritis (all common types except lupus nephritis), but was seen also in respect of type I diabetic nephropathy, hypertensive renal disease and analgesic nephropathy, while the excess in Maori and Pacific Island people was confined to type II diabetic nephropathy, hypertensive renal disease and glomerulonephritis (especially lupus nephritis and type I mesangiocapillary glomerulonephritis, but not mesangial IgA disease). CONCLUSIONS: The incidence and pattern of treated ESRD differs quantitatively and qualitatively between Maori, Pacific Island people and other New Zealanders, and Indigenous and non-indigenous Australians.     

Incidence of end-stage renal disease in overseas-born, compared with Australian-born, non-indigenous Australians

BACKGROUND: Barriers to immigration from non-European sources were relaxed in the 1970s. As a result, more Australians are now of Middle Eastern, Asian or Pacific Islander origin, rather than British or European. Currently, overseas-born persons comprise one-third of non-indigenous Australians with end-stage renal disease (ESRD). METHODS: Using data recorded by the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, age-standardized incidence rates were calculated for ESRD due to all causes and to certain primary renal diseases for all non-indigenous Australians who were aged over 15 years when first treated for ESRD between 1993 and 2001. Truncated age-standardized incidence rates were calculated for ESRD due to glomerulonephritis by type. RESULTS: Immigrants from the British Isles and 'rest of Europe' had less, and those from the Pacific Island nations, East/South-East Asia, Indian subcontinent, Middle East and Southern Europe more ESRD from all causes than the Australian-born. Two diseases accounted for most of the excess: Type 2 diabetic nephropathy and glomerulonephritis (the latter not significant for the Indian-born). There was a small excess (not always significant) of hypertensive/arteriopathic renal disease in Asian- and Middle Eastern-born persons. The East/South-East Asian-born had the highest rates of ESRD due to mesangial immunoglobulin A (IgA) disease and lupus nephritis, and the Middle Eastern-born the highest rates from focal sclerosing glomerulonephritis. CONCLUSION: For Australians born in the Pacific Island nations, Asia, the Middle East or Southern Europe, excess prevalence of, and/or susceptibility to, diseases that cause ESRD has more than offset any 'healthy migrant' effect.     

Current incidence, treatment patterns and outcome of end-stage renal disease among indigenous groups in Australia and New Zealand

SUMMARY: The changes in rates of treated end-stage renal disease (ESRD) among indigenous populations have profound consequences for those individuals affected and for health-care providers. By using data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry, we examined the current incidence, treatment and outcomes of ESRD among indigenous groups in Australia and New Zealand. All patients who began renal replacement therapy (RRT) in Australia or New Zealand between October 1991 and September 2000 were included. Rates of ESRD, RRT modalities, renal transplantation and mortality were the outcomes examined. End-stage renal disease rates among indigenous groups in Australia and New Zealand exceeded non-indigenous rates up to eightfold. The median age of indigenous ESRD patients was younger (51 vs 60 years, P  < 0.0001), and there was an excess of comorbidities, particularly diabetes. For Australian Aboriginal and Torres Strait Islanders, and New Zealand Maori patients, mortality rates across all modalities of RRT were 70% higher than non-indigenous rates. Indigenous people were less likely to receive a renal transplant prior to dialysis treatment, less likely to be accepted onto the cadaveric transplant waiting list, and less likely to receive a well-matched transplant. The poorer outcomes among Australian Aboriginal and Torres Strait Islanders, and New Zealand Maori patients did not appear to be explained by the different comorbid conditions or age. Whether the outcomes reflect unmeasured differences in disease burden or treatment differences is not known. Tackling this problem will involve a spectrum of people and approaches, from tertiary care providers and RRT to local staff and preventative programs.     

Increases in renal replacement therapy in Australia and New Zealand: understanding trends in diabetic nephropathy

Aim: The incidence of end‐stage kidney disease (ESKD) has been increasing worldwide, with increasing numbers of older people, people with diabetic nephropathy and indigenous people. We investigated the incidence of renal replacement therapy (RRT) in Australia and New Zealand (NZ) to better understand the causes of these effects. Methods: Data from the Australia and New Zealand Dialysis and Transplant Registry (ANZDATA)registry and relevant population data were used to investigate the incidence of RRT in five demographic groups: Indigenous and non‐indigenous Australians, Māori, Pacific Islanders and other New Zealanders, as well as differences between genders and age groups. Results: The numbers of patients commencing RRT each year increased by 321% between 1990 and 2009. This increase was largely driven by increases in patients with diabetic nephropathy. In 2009 35% of new patients had ESKD resulting from diabetic nephropathy 92% of which were type 2. Indigenous Australians, and Māori and Pacific people of NZ have elevated risks of commencing RRT due to diabetic nephropathy, although the risks compared with non‐indigenous Australians have decreased over time. A small element of lead time bias also contributed to this increase. Males are more likely to commence RRT due to diabetes than females, except among Australian Aborigines, where females are more at risk. There is a marked increase in older, more comorbid patients. Conclusions: Patterns of incident renal replacement therapy strongly reflect the prevalence of diabetes within these groups. In addition, other factors such as reduced risk of dying before reaching ESKD, and increased acceptance of older and sicker patients are also contributing to increases in incidence of RRT.     

Incidence and treatment of ESRD among indigenous peoples of Australasia

Indigenous people in Australia and New Zealand experience rates of ESKD several times higher than non-indigenous people. This relative rate is highest among people aged 45 - 54 for Aboriginal Australians, and 65 - 74 years for Maori. The majority of this is driven by diabetic nephropathy. Both groups have lesser utilization of transplantation as a renal replacement therapy than non-indigenous comparators, and lesser utilization of home dialysis modalities.     

Barriers to access by Indigenous Australians to kidney transplantation: the IMPAKT study

Although Indigenous Australians represent less than 2% of the national population, they account for 8-10% of new patients commencing treatment for end-stage renal disease (ESRD). Almost half come from remote regions lacking renal disease treatment services. In those regions, their incidence of ESRD is up to 30 times the incidence for all Australians. Kidney transplantation is the optimal treatment for ESRD. Compared with long-term dialysis, it results in better quality of life, longer life expectancy and lower costs of health care. Indigenous Australians with ESRD receive transplants at approximately one-third the rate of non-Indigenous patients. There are similar disparities in access to kidney transplants for Native Americans, Aboriginal Canadians and New Zealander Maori. The reasons for such disparities have not been studied in any detail. IMPAKT (Improving Patient Access to Kidney Transplantation) is an NHMRC-funded study, involving eight major renal units. It aims to identify the reasons for Indigenous Australians' poor access to transplantation. It will systematically examine each of the steps a new dialysis patient must negotiate in order to receive a transplant. Each of these steps can become a barrier.     

Geographic, ethnic, age-related and temporal variation in the incidence of end-stage renal disease in Europe, Canada and the Asia-Pacific region, 1998-2002.

BACKGROUND: Only unbiased estimates of end-stage renal disease (ESRD) incidence and trends are useful for disease control-identification of risk factors and measuring the effect of intervention. METHODS: Age- and sex-standardized incidences (with trends) were calculated for all-cause and diabetic/non-diabetic ESRD for persons aged 0-14, 15-29, 30-44 and 45-64 years in 13 populations identified geographically, and six populations identified by ethnicity. RESULTS: The incidence of ESRD varied most with age, ethnicity and prevalence of diabetes. All non-Europid populations had excess ESRD, chiefly due to rates of type 2 diabetic ESRD that were greater than accounted for by community prevalences of diabetes. Their rates of non-diabetic ESRD also were raised, with contributions from most common primary renal diseases except type 1 diabetic nephropathy and polycystic kidney disease. The ESRD rates generally were low, and more similar than different, in Europid populations, except for variable contributions from type 1 (high in Finland, Sweden, Denmark and Canada) and type 2 (high in Austria and Canada) diabetes. In Europid populations during 1998-2002, all-cause ESRD declined by 2% per year in persons aged 0-44 years, and all non-diabetic ESRD by a similar amount in persons aged 45-64 years, in whom diabetic ESRD had increased by 3% per year. CONCLUSIONS: Increased susceptibility to type 2 diabetes and to kidney disease progression characterizes excess ESRD in non-Europid peoples. The decline in all-cause ESRD in young persons, and non-diabetic ESRD in the middle-aged, probably reflects improving management of progressive renal disease.     

Barriers to access by Indigenous Australians to kidney transplantation: The IMPAKT study

SUMMARY:   Although Indigenous Australians represent less than 2% of the national population, they account for 8–10% of new patients commencing treatment for end-stage renal disease (ESRD). Almost half come from remote regions lacking renal disease treatment services. In those regions, their incidence of ESRD is up to 30 times the incidence for all Australians.
Kidney transplantation is the optimal treatment for ESRD. Compared with long-term dialysis, it results in better quality of life, longer life expectancy and lower costs of health care. Indigenous Australians with ESRD receive transplants at approximately one-third the rate of non-Indigenous patients. There are similar disparities in access to kidney transplants for Native Americans, Aboriginal Canadians and New Zealander Maori. The reasons for such disparities have not been studied in any detail.
IMPAKT (Improving Patient Access to Kidney Transplantation) is an NHMRC-funded study, involving eight major renal units. It aims to identify the reasons for Indigenous Australians' poor access to transplantation. It will systematically examine each of the steps a new dialysis patient must negotiate in order to receive a transplant. Each of these steps can become a barrier.     

Burden of end-stage renal disease among indigenous peoples in Australia and New Zealand

Rates of end-stage renal disease (ESRD) among indigenous people in Australia and New Zealand are considerably higher than the non-indigenous population. This trend, apparent for several years, is described here using data from the Australia & New Zealand Dialysis and Transplant (ANZDATA) Registry. The average age at start of renal replacement therapy (RRT) is approximately 10 years less than non-indigenous people. Among those starting RRT, rates of "diabetic nephropathy" are higher among indigenous patients, reflecting higher rates of diabetes. The increased burden of illness extends to coronary artery disease and chronic lung disease, which are present at rates 1.5 to 2 times non-indigenous rates. Once dialysis treatment has commenced, indigenous people are less likely to be placed on the active cadaveric transplant waiting list, and less likely to receive a graft. Overall mortality outcomes are poorer for indigenous patients overall, and for each RRT modality. These outcomes are not simply due to increased frequency of co-morbid illness: for indigenous people receiving dialysis treatment the mortality rate adjusted for age and gender is around 11/2 times the non-indigenous rate. These data are consistent with studies showing increased rates of markers of early renal disease (in particular albuminuria) among both Australian and New Zealand indigenous groups, and reflect a broader health profile marked by high rates of diabetes, cardiovascular disease and chronic lung disease. Addressing these issues is a major challenge for health care providers in these regions.     

Trends in incidence of treated end-stage renal disease, overall and by primary renal disease, in persons aged 20-64 years in Europe, Canada and the Asia-Pacific region, 1998-2002

AIMS: To determine if rates of diabetic and non-diabetic end-stage renal disease (ESRD), which had been rising in young and middle-aged adults in all populations up to the mid-1990s, had started to decline, and if so, whether improvement had occurred in respect of each of the principal primary renal diseases causing ESRD. METHODS: Poisson regression of age- and sex-standardized incidence of ESRD for persons aged 20-64 years in 18 populations from Europe, Canada and the Asia-Pacific region, for 1998-2002. RESULTS: In persons from 12 European descent (Europid) populations combined, there was a small downward trend in all-cause ESRD (-1.7% per year, P = 0.001), with type 1 diabetic ESRD falling by 7.8% per year (P < 0.001), glomerulonephritic ESRD by 3.1% per year (P = 0.001), and 'all other non-diabetic' ESRD by 2.5% per year (P = 0.02). The reductions in ESRD attributed to hypertensive (-2.2% per year) and polycystic renal disease (-1.5% per year) and unknown diagnosis (-0.2% per year) were not statistically significant. On the other hand, the incidence of type 2 diabetic ESRD rose by 9.9% per year (P < 0.001) in the combined Europid population, although that of (principally type 2) diabetic ESRD remained unchanged in the pooled data from the four non-Europid populations. CONCLUSION: Recent preventive strategies, probably chiefly modern renoprotective treatment, appear to have been effective for tertiary prevention of ESRD caused by the proteinuric nephropathies other than type 2 diabetic nephropathy, for which the continuing increase in Europid populations represents a failure of prevention and/or a change in the nephropathic potential of type 2 diabetes.     

Trends in incidence of end-stage renal disease in Japan, 1983-2000: age-adjusted and age-specific rates by gender and cause.

BACKGROUND: Trends in age-adjusted or age-specific incidence rates of end-stage renal disease (ESRD) have never been examined in Japan, a major ESRD epidemic area. METHODS: A nationwide registry has provided the number of ESRD patients commencing maintenance renal replacement therapy for time period from 1983 to 2000. We computed gender- and age-specific incidence rates of ESRD over 2-year periods, in total or by cause. Age-adjusted incidence rates were calculated using the 1985 Model Population of Japan as the standard. RESULTS: Causes of ESRD in 1999-2000 were, in order of decreasing frequency, diabetic nephropathy, chronic glomerulonephritis, unknown causes, nephrosclerosis and polycystic kidney disease in men, and chronic glomerulonephritis, diabetic nephropathy, unknown causes, nephrosclerosis and polycystic kidney disease in women. The age-adjusted all-cause incidence of ESRD increased until 1995-1996, but has since levelled off in both genders. The age-adjusted rate for diabetic nephropathy has been rapidly increasing, while that for chronic glomerulonephritis has decreased since 1995-1996. The former rate exceeded the latter in 1997-1998 in men. All-cause ESRD has rapidly increased in the eighties age group, whereas the increase slowed down in younger age groups in the late 1990s. The rate for diabetic nephropathy has linearly risen in almost every age group in men, whereas it began to level off in women aged 40-59 years at about 1995. For chronic glomerulonephritis, the rate had already started to decline in the mid-1980s in those aged <45 years. The rate of nephrosclerosis has been increasing independently of age. CONCLUSIONS: The present study shows changes in the epidemiological features of the incidence of ESRD in Japan from 1983 to 2000.     

Different regional dynamics of end-stage renal disease in Japan by different causes

BACKGROUND: We recently showed that there were clear regional differences in the dynamics of end-stage renal disease (ESRD) within Japan, which has an ethnically homogenous population. We speculate on the reason for these regional differences by correlating the regional distributions in the incidence of ESRD due to each of the following individual causes of ESRD: chronic glomerulonephritis (CGN), diabetic nephropathy (DMN) and polycystic kidney disease (PKD). METHODS: The number of ESRD patients entering maintenance dialysis therapy due to individual causes of renal disease in each prefecture was reported annually for a 6-year period by the Japanese Society for Dialysis Therapy. After combining data from several prefectures into 11 geopolitical regions in Japan, the mean annual incidence of ESRD across the 11 regions was correlated among the three causes of ESRD. RESULTS: There were significant regional differences in the incidence of ESRD due to CGN (P<0.0001) and DMN (P=0.0015), the distributions of which were similar to each other across the 11 regions. In contrast, no regional differences were found in the incidence of ESRD due to PKD (P=0.6) as the major genetic disorder of the kidneys, suggesting that genetic backgrounds are relatively uniform throughout Japan. The regional distributions due to PKD were not correlated with those due to other causes: CGN and DMN. CONCLUSION: Risk factors common to nephropathy progression, rather than an underlying disease incidence and genetic predisposition, might contribute to regional differences in the overall ESRD incidence in Japan. Other possibilities such as the prevalence of underlying diseases, and acceptance or rejection rates into treatment programmes must be considered further for better explanations.     

An expanded nationwide view of chronic kidney disease in Aboriginal Australians

We summarize new knowledge that has accrued in recent years on chronic kidney disease (CKD) in Indigenous Australians. CKD refers to all stages of preterminal kidney disease, including end‐stage kidney failure (ESKF), whether or not a person receives renal replacement therapy (RRT). Recently recorded rates of ESKF, RRT, non‐dialysis CKD hospitalizations and CKD attributed deaths were, respectively, more than sixfold, eightfold, eightfold and threefold those of non‐Indigenous Australians, with age adjustment, although all except the RRT rates are still under‐enumerated. However, the nationwide average Indigenous incidence rate of RRT appears to have stabilized. The median age of Indigenous people with ESKF was about 30 years less than for non‐Indigenous people, and 84% of them received RTT, while only half of non‐Indigenous people with ESKF did so. The first‐ever (2012) nationwide health survey data showed elevated levels of CKD markers in Indigenous people at the community level. For all CKD parameters, rates among Indigenous people themselves were strikingly correlated with increasing remoteness of residence and socio‐economic disadvantage, and there was a female predominance in remote areas. The burden of renal disease in Australian Indigenous people is seriously understated by Global Burden of Disease Mortality methodology, because it employs underlying cause of death only, and because deaths of people on RRT are frequently attributed to non‐renal causes. These data give a much expanded view of CKD in Aboriginal people. Methodologic approaches must be remedied for a full appreciation of the burden, costs and outcomes of the disease, to direct appropriate policy development.     

Factors influencing reported rates of treated end-stage renal disease

Rates of treated end-stage renal disease have risen relentlessly throughout the Western world over the past 30 years, with little indication of a slowing in the rate. This increase has a number of causes, such as important trends in disease prevalence, changing population structure, and changing treatment patterns. A number of biases also affect measured rates of renal replacement therapy. These biases include lead-time and length bias, as well as classification bias. A further important effect will be changes in competing risks, in particular, changing mortality from cardiovascular disease. We examine the effects of these factors by analyzing data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry. Rates of treated ESRD have risen steadily over the past 30 years, which appears to be the result of several factors. Rates among older people have increased particularly, as have rates among Australian and New Zealand indigenous peoples. Higher rates are also seen among some immigrant groups. Accentuating the effect of these changing rates are changes in the structure of the population and the tendency to commence treatment earlier. The increase in rates of ESRD treatment is often ascribed to an explosion of kidney disease. Although a major contribution comes from increasing disease prevalence, understanding the implications of this increase requires comprehension of a number of other factors.     

Renal-related deaths in Indigenous people in Queensland, Australia

AIM: Indigenous Australians have much higher mortality than non-Indigenous Australians. We aimed to quantify the excess of deaths with a renal causal assignment among Indigenous people aged 25 years and over in Queensland, Australia, 1997-2000 and their distribution by remoteness. METHODS: Both underlying and associated causes defined by ICD, 10(th) edition, were examined. Mortality rates were standardized to the concurrent non-Indigenous population. RESULTS: In Indigenous people, standardized mortality ratios with a renal assignment of death by remoteness of residence were 194% (Major City and Inner Regional), 439% (Outer Regional and Remote) and 782% (Very Remote). Of all these deaths with a renal assignment, only 18% had a renal assignment as the underlying cause. Diabetes and cardiovascular disease were frequent concomitant causes in deaths with a renal assignment. CONCLUSION: The Indigenous population in Queensland has elevated rates of renal deaths compared with the non-Indigenous population. This disparity increases markedly with increasing remoteness of residence. Reliance on underlying causes of death alone greatly underestimates the association of renal disease with deaths in this population.     

Proposal for mapping renal failure in Japan and its application for strategy to arrest endstage renal disease

Remarkable regional differences in the annual incidence of endstage renal disease (ESRD) was found within Japan, which has a relatively homogeneous ethnic composition. In addition, there existed no regional difference in the incidence of ESRD due to polycystic kidney disease, the major genetic disorder of the kidneys. These findings suggest that the presence of factors other than genetic disposition contribute to the differences. On the other hand, there were similar regional variations in the incidences of ESRD between two causes of ESRD: chronic glomerulonephritis and diabetic nephropathy. Because it is unlikely that the regional distribution of underlying disease incidence and the disease-specific progression rate would be similar for two different causes, this observation suggests that factors governing the progression rate, which operate commonly for all causes of ESRD but differ among regions, may play an important role in generating the regional differences. Finally, we examined regional differences in the amounts of inhibitors of the renin-angiotensin system used, especially angiotensin-converting enzyme (ACE) inhibitors, in our search for an explanation of the regional differences in ESRD dynamics. Among antihypertensive agents examined, only ACE inhibitors were negatively correlated with the annual incidence of ESRD. The renal protective effects of ACE inhibitors have been established by results with animal models of progressive nephropathy and by large-scale clinical trials. Our epidemiological results for Japan as a whole show the same protective effects still more convincingly from a different approach. It is not completely clear yet at present, however, how regional variations in the incidence of ESRD are generated. If we could identify in future the factors that contribute to the regional differences, strategies for the treatment of renal disease will become available from different angles. Thus, much effort will be encouraged for the further analysis of regional differences in ESRD dynamics. This article was presented as the Oshima Award memorial lecture at the 48th annual meeting of the Japanese Society of Nephrology, held at Yokohama, Japan, on June 24, 2005.     

Patterns of low incidence of treated end-stage renal disease among the elderly.

We present US county-level maps of the 1983 to 1988 incidence of treated end-stage renal disease (ESRD) among white and nonwhite persons 65 years of age and older (N = 66,129). Recent statistical advances permit the investigation of geographical patterns of unusually low disease incidence. Our maps highlight those US counties which have been determined to have rates of ESRD treatment incidence that are low relative to those of all counties, revealing several interesting geographic patterns. For whites, low rates are found in the Northwest, the Midwest, and the South. Nonwhite rates are seen to be low primarily in the South and Alaska. Low treatment incidence could be due to a combination of (1) low true incidence, (2) lack of access to health care services, (3) insufficient diagnosis and referral, and (4) patients' reluctance to accept ESRD therapy, due to cultural or personal concerns. A state-level regression of elderly rates on those aged 40 to 64 years indicates the variation in treatment incidence among the elderly may be due to factors other than variation in true incidence, which the middle-aged rates reflect more closely. Residual analysis corroborates the visual impression of the maps of low ESRD treatment incidence in several southern states, where referral to dialysis may be as much as 40% lower than the national level. Further research on factors contributing to low treatment incidence, including competing risks, regional lags relative to the national trend to dialyze more elderly patients, and lack of access to health care resources, is indicated.     

Renal transplantation in indigenous populations

Summary: Renal disease is a common problem in many indigenous populations, but the treatment of endstage renal disease (ESRD) by dialysis and transplantation presents special problems in such populations. Many of these problems are illustrated by the attempts to provide renal transplantation for the Aboriginal Australian population. Factors such as cost, religious and cultural attitudes, endemic infections, causes of end-stage renal failure, compliance, race, logistic problems and equitable allocation of organs influence not only the provision of transplantation but also its outcome. In developing countries where cost is the overriding factor determining provision, transplantation even in the non-indigenous populations is rarely a practical option for ESRD. In developed and affluent countries, such as Australia, cost is not the major factor to be considered in providing a satisfactory renal transplant program. Cultural attitudes, compliance, logistic problems, and the equitable allocation of organs are greater problems. Nevertheless in developed countries such as Australia it should be possible to provide successful renal transplantation for the indigenous population with ESRD provided that it is accompanied by intense programs of disease prevention, after identification of the causes and risk factors of renal disease. Furthermore, a successful program will only be developed if it involves the indigenous communities themselves in the development and maintenance of the program.     

Kidney transplant outcomes in the indigenous population in the Northern Territory of Australia

BACKGROUND: Indigenous Australians develop end-stage renal disease (ESRD) at a significantly higher rate than nonindigenous Australians. Renal transplantation is the preferred treatment modality; however, they are underrepresented in the transplanted population. In addition, despite the morbidity and mortality gains demonstrated in other patient groups, it is unclear whether such an advantage is replicated for indigenous Australians. We have sought to identify some of the factors that lead to poorer outcomes within this group of recipients. METHODS: We performed a retrospective analysis of a cohort of renal transplant recipients (indigenous and nonindigenous) from the Northern Territory of Australia. RESULTS: Indigenous patients waited longer on dialysis, were more sensitized at the time of transplantation, and the number of human leukocyte antigen mismatches was greater. Overall renal allograft survival is poorer among indigenous Australians (HR 4.13, 2.0-8.5, P<0.0001) with the majority of grafts lost due to recipient death. The most common cause of death was septicemia. Graft loss due to any cause has not been influenced by the absence of full-time specialist staff at major treatment centers. Infection rates are greatly increased in indigenous patients (RR 4.1, 95% CI 3.5-4.7, P<0.0001), in addition to the incidence of rejection (RR 2.5 95% CI 1.8-3.5, P<0.001) and hospitalization (RR 3.9, 95% CI 3.2-4.9, P<0.0001). There is increased steroid exposure among indigenous recipients. CONCLUSIONS: Indigenous recipients of cadaveric kidney transplants have worse outcomes than nonindigenous recipients, mostly due to increased mortality and morbidity from infective causes.     

Results of treatment in patients with end-stage renal disease: a multivariate analysis of risk factors and survival in 341 successive patients

Factors that affect survival in patients with end-stage renal disease (ESRD) are still only partially understood. We report an analysis on a cohort of 341 successive patients who started ESRD treatment in one institution. Survival was calculated from the start of ESRD treatment, whether initial treatment was by dialysis (335 patients) or transplantation (6 patients). Analysis of factors affecting survival was done using the Cox multivariate hazard analysis. Relative risks were calculated for several demographic factors, the primary renal disease, the presence or absence of various high-risk co-morbid factors, and for a first transplant from a living-related or cadaver donor. Older patients, patients with no prior health insurance, those with diabetic nephropathy, and those with small kidneys of unknown cause had statistically significantly higher risks of dying. The risk of dying decreased by year of start of ESRD treatment. Living related donor transplantation was associated with a decreased hazard to age 45 years and older; whereas cadaver donor transplantation was associated with a hazard that increased with age and was significantly increased by age 45.